Healthcare Provider Details

I. General information

NPI: 1801872494
Provider Name (Legal Business Name): KATHRYN LANDON-MALONE PNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICKHILL AVE SUTIE 304
SOUTH PORTLAND ME
04106-1999
US

IV. Provider business mailing address

100 BRICKHILL AVE SUITE 304
SOUTH PORTLAND ME
04106-1999
US

V. Phone/Fax

Practice location:
  • Phone: 207-761-4700
  • Fax: 207-761-4744
Mailing address:
  • Phone: 207-761-4700
  • Fax: 207-761-4744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR038746
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: